Will be live tweeting this multi-disciplinary webinar on COVID intubation from Canadian Anesthesia Society. Featuring expertise from Canadian anesthesiologists, critical care and emergency medicine. Will thread tweets below.
"doing things safely" is the title of the webinar and focus of the conversation.
thanks @drlauraduggan for acknowledging information overload plus anxiety during preparation period. Goal today = slow down and focus on priorities for COVID a/w management
First bit is a review of the worldwide stats and COVID19 epidemiology.
Quite a few key papers quickly reviewed at start of webinar. This is an alarming stat but apparently early in outbreak - infective load may be increased in HCW and thus increased severity and mortality. Very worrying. 
This slide covering papers looking at intubation which seems reassuring that PPE works to protect airway managers.
Cannot talk about airway management without talking about PPE. Critical piece of the puzzle.
@drlauraduggan referencing this paper to talk about risk of AGMP and comparing different procedures. Level/quality of evdience in this syst review poor and includes observational studies. Note this is pre-Covid19
New techniques with airway management now since SARSv1. First point: 2 hand 2 operator BMV achieves better seal with less pressure.
Video laryngoscopy has better 1st pass success rate. Note that video scopes have 2 kinds of blades - mac blade with hyperangulated. Recommended for intubation of COVID patient
COVID pneumonic to remember steps. Importance of team members looking out for each other for PPE donning and DOFFING - most hazardous procedure and you must have a spotter.
Now moving on to case studies:
1st one is Covid patient in resp distress. When to intubate? Q to panel.
1st one is Covid patient in resp distress. When to intubate? Q to panel.
No clear consensus out there. Varying FiO2 requirements wth intubation recommendations. Emerging literature suggesting that some pts do well without intubation even when ++ hypoxic
Need to find balance between intubation before it becomes crash and avoiding unnecessary intubation. Early airway management prior to decompensation is the underlying principle. May differ from site to site.
Q to panel - WHERE should this patient be intubated? (resp distress needing intubation). A: negative pressure room? Yes if available = optimal. Reality is rarely available for majority of patients. Should be done where providers can don PPE and where optimal preparation possible
Q to Tim Cook about optimal preoxygenation - how and what?
Moving away from the idea that NIV and high flow O2 are dangerous. Agrees with intubation before decompensation. But also do not throw away other methods for maintaining oxygen support.
If this pt decompensates do not start NIV but if already in place maintain - providers are wearing airborne PPE!
@georgemastoras agrees that throwing out NIV and high flow O2 for all COVID pts is not a great idea. But should we use these devices to preoxygenate? Limited number of devices. Not sure thats a good way to pre-ox - thinks BMW with good seal better option
@drlauraduggan says growing body of evidence about types of droplets from these oxygenation methods differing - stay tuned for evolving estimates
Shout out to airway expert @kovacsgj as they mention the importance of Hepa filter attached to BMV in reducing risk of droplet spread
Filter must go closest to patient to protect hcw in room
Now talking about drugs. Full paralysis using doses that are higher than what we are used to - optimize 1st pass success.
High risk procedure. @drlauraduggan recommends optimal PPE - improved first pass success with providers who feel protected during procedure
Principles of PPE especially during shortages - neck protection (as example) may look different. Might be a shower if no neck covers available. Will evolve as shortages change
Outside the room preparation. Standardized equipment and set-up and simulation *strongly recommended* by panel. (personal note - we have certainly benefitted from sim @Qemerg and @KingstonHSC )
Standardized identical bins (A,B and C) shown - Ottawa. Recommend this approach to institutional standard setup.
Standardization and predictability = fundamental principles. Here is the set-up in England for Tim Cook.
Point about the circuit set-up - should be closed ("un-disconnected") as much as possible. Hepa filter next to patient. If disconnected then use a clamp and stop ventilation while circuit opened. Clamp beside every intubated patient? (I'm going to say YES!)
Point made that this is a great thing to start practicing now. Drill this during sims and with other intubated patients - CLAMP when you disconnect (i.e. switch from BMV to ventilator)
This is not the time to try new things on the fly. Predictability of your actions and your team essential for this - again the importance of simulation to create shared mental model.
Recommended set-up in room from @doctimcook
Another mention of CRITICAL IMPORTANCE of standardized process with tight control. Decide on your approach and practice it.
The standardized approach may be modified as the pandemic progresses in Canada. (personal comment - we are used to individual recipes and approaches to a/w management - we need to change that for this to protect the team and optimize success)
In-situ sim must be done to train everyone on team. I'm going to stop tweeting it but it is being constantly stressed by everyone on panel.
Recommend large screen (left photo) instead of small screen (right photo) video laryngoscope tower.
Check your video laryngoscope tower - strip it down so that components not contaminated. Nothing on it that is not part of covid intubation plan A
Might have de-linked tweet about stripping down the tower - if you have a video laryngoscopy tower strip it down or the stuff on it will get contaminated. (Marie Kondo your tower)
Recommend against cricoid pressure. Comment from anesthesiologist about risk of airway distortion. (note - I think ER MDs have mostly abandoned cricoid pressure for full stomach intubations for this reasons and others)
Recommend cognitive aids like checklists. STRONGLY recommend development or adoption of institutional checklist and then PRACTICE with them. Very helpful in reducing cognitive load.
Intubate by protocol: here is recommended cocktail:
Standardized drug protocol reduces cognitive load and allows a shared mental model for your team. (personal note - this is not the time to insist on your own personal signature cocktail for intubation)
Many reports of patients arresting on intubation. Remember the primary principle - arrest after intubation = CHECK THE TUBE. If no capnography trace the tube is in the wrong place.
Flat capnograph = ETT is esophageal.
Failure to intubate on first attempt. Here is the recommended plan.
retweeting bc out of thread. Failed 1st pass intubation? Here is recommended plan.
O2 sats will sink like a stone. BMV 2-person technique with careful gentle ventilation is most people's recommended step 2. Rescue supraglottic airway - use a later generation device with good seal. And PRACTICE it.
Doff slowly with a spotter. Point again that doffing is the most risky part of this entire procedure.
some ppl have recommended doff looking in a mirror. PANEL DISAGREES. Using a spotter is evidence-based method to reduce errors and contamination.
Another case - need to intubate a trauma. Approach as covid positive? Panel says yes - most centres have community spread. You may be able to scale down if good evidence that self isolated x 2 weeks and no symptoms.
Cardiac arrest? First responders must have airborne precautions prior to initiation of BCLS/ACLS. Should be routine in centres with community spread.
Code blue in hospital - who is airway manager? SOme centres have modified on call so that in hospital airways have staff anesthesiologist (principle - standardized approach with staff protection and best airway manager to perform procedure)
Q about extubation. Panel suggesting avoid coughing during extubation. Nuanced individual practice for this (IV lidocaine mentioned). Deep extubation? This is not the time to start doing this. Extubate deep and replace with supraglottic? maybe if its your routine practice.
apply mask over patients face, use a filter are the recommended extubation steps then some individual variability. (I don't do this routinely so may have missed some content here)
Airway collaboration is collecting anonymous data to try to ascertain hcw transmission information and learn more about PPE.
Panel wrapping up. Now answering questions - Q who is intubating in your hospitals? Is there an intubation team?
A - UK and Italy have convened institutional mobile intubation teams. All intubations done by dedicated team
A - UK and Italy have convened institutional mobile intubation teams. All intubations done by dedicated team
Comment from Vancouver - also has a dedicated team for intubation within hospital led by anesthesia. Vancouver has a tent outside the ED for crash intubations with no time to call anesthesia led team and ED does the crash tubes there
@georgemastoras stressing need for open lines of communication and cross-disciplinary collaboration. Ottawa does not yet have dedicated intubation team but discussions ongoing.
Summary comments. These are physiologically difficult airways but not *usually* anatomically difficult airways. However - remember that awake techniques are contraindicated here. Anything that makes patients cough is BAD.
If anticipated very difficult airway may mean different decisions (i.e. front of neck access as initial attempt). First priority is to protect staff.
Some variation of opinion on panel about black and white nature of awake intubation being contraindicated. This is a difficult situation and decision.
OK we are wrapping up. Here are my key takeaways. 1) develop shared mental model with team. 2) practice (SIMULATION) and use aids to relieve cognitive load checklists etc 3) Standardized approach across institution for drugs and technique
4) Many sample approaches and guidance from groups who have thought a lot about this and have lived experience. Use their work which is shared ++ on many platforms (including this webinar which will also be shared).
Please let me know @drlauraduggan @georgemastoras and @doctimcook if I have missed or misheard key takeaways. Very helpful and thank you for putting together!
